An Analysis Of Wrong Site And Wrong Patient Surgeries

A study reported in 2010 of wrong site and wrong patient surgeries was based on an analysis of a database covering the period from January 1, 2002 to June 1, 2008 of a Colorado medical malpractice insurance company that insured approximately 6,000 physicians in Colorado. The database included 27,370 reports of adverse occurrences that were self-reported by physicians.

The study found 25 wrong patient procedures and 107 wrong site procedures, resulting in significant harm in 5 wrong patient procedures (prostatectomies on the wrong patients due to mislabeling of biopsy samples (3), a virectomy on the wrong patient due to two patents with the identical names in the ophthalmologist’s office, and a  myringotomy in a child scheduled for an adenoidectomy due to bringing the wrong child to the operating room) and resulting in significant harm in 38 wrong site procedures (wrong-level spine surgery (5), wrong-sided chest tube placement (4), wrong-site vascular procedure (4), wrong-part enterocolic resection (4), wrong-organ resection (4), wrong-site upper extremity surgery (3), wrong-sided lower extremity surgery (3), wrong-sided ovariectomy (2), wrong-sided eye surgery (2), wrong-sided craniotomy (2), wrong-sided ureteric procedure (2), wrong-sided maxillofacial suregry (1), and unintentional irradiation of an untargeted organ outside the onocologic radiation field (2)). There was one death associated with a wrong site procedure (acute respiratory failure after a wrong-sided placement of a chest tube). There was no harm in 36% of the wrong patient procedures and no harm in 2.8% of the wrong site procedures.

The study found that errors in diagnosis (56%) and errors in communications (100%) were the main causes of wrong patient procedures. Errors in judgment (85%) and lack of performing a “time-out” (72%) were the main causes of wrong site procedures.

The medical specialties most involved in wrong patient procedures were internal medicine (24%), family or general practice, pathology, urology, obstetrics-gynecology, and pediatrics (8% each). The medical specialties most involved in wrong site procedures were orthopedic surgery (22.4%), general surgery (16.8%), and anesthesiology (12.1%).

A task force from the American Academy of Orthopaedic Surgeons reported in 1998 that orthopedic surgeons had a 25% chance of performing a wrong site surgery during a 35 year career. The risk was particularly high for wrong-knee arthroscopies and wrong level spine fusions.

It was reported that approximately one-third of wrong site procedures result in litigation. There was no monetary demand in 48% of the wrong site procedures and 70% of the wrong patient procedures. A monetary demand was made in 19% of the wrong site procedures and 17% of the wrong patient procedures that did not involve a lawsuit. Compensation was offered in 25% of the wrong site procedures and in 10% of the wrong patient procedures, before a monetary demand was received. The average payment made in wrong site procedures was $47,216 and the average payment made in wrong patient procedures was $2,813. Seven percent (7%) of the wrong site procedures and 3% of the wrong patient procedures involved litigation. The average cost for the wrong site procedures that involved litigation was $80,041 and the average cost for the wrong patient procedures that involved litigation was $46,172.

In effort to reduce wrong site and wrong patient surgeries, a Universal Protocol was established and became effective on July 1, 2004 for all accredited hospitals, ambulatory care facilities, and office-based surgical facilities that consists of three distinct parts: a preprocedure verification, a surgical site marking, and a “time-out” performed immediately before the surgical procedure.


If you or a loved one have been injured due to surgery on the wrong site or surgery on the wrong patient, you may be entitled to monetary compensation for your losses. Visit our website to be connected with local medical malpractice lawyers who may be able to represent you with your possible medical malpractice claim or call us toll free 800-295-3959.

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This entry was posted on Thursday, September 8th, 2011 at 10:44 am. Both comments and pings are currently closed.


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